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Phase 2 > General Surgery > Flashcards

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

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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
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3
Q

What are the therapeutic indications for colonoscopy?

A 
Haemostasis
Bleeding angiodysplasia lesion
Volvulus untwisting
Pseudo-obstruction
Polypectomy
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4
Q

What sedatives can be used in endoscopy?

A

Medazolam to remain conscious

Propofol for GA

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5
Q

What is duodenal biopsy used for?

A

Gold standard diagnosis of Coeliac disease

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6
Q

How far can a sigmoidoscopy view?

A

Rectum and sigmoid colon up to splenic flexure

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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

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8
Q

What bowel prep is used for colonoscopy?

A

Sodium picosulfate morning and afternoon day before

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9
Q

What are the potential complications of colonoscopy?

A

Abdominal discomfort
Incomplete examination
Haemorrhage after biopsy or Polypectomy
Perforation

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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

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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

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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

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13
Q

What medications are used to treat peptic disorders?

A

Antacids
Alginates
H2 receptor antagonist
PPI

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14
Q

What is triple therapy for peptic ulcers?

A

PPI

2 antibiotics

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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

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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
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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

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18
Q

Why may vitamin B12 deficiency happen after gastric surgery?

A

No intrinsic factor production

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19
Q

What is a Billroth I procedure?

A

Partial Gastrectomy with simple gastroduodenal re-anastomosis

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20
Q

What is a Billroth II procedure?

A

Partial gastrectomy with gastrojejunal anastomosis

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21
Q

What is a Roux-en-Y procedure?

A

Anastomosis between stomach and part of small bowel distal to the cut end

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22
Q

When is surgery indicated for peptic ulcers?

A

Haemorrhage
Perforation
Pyloric stenosis

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23
Q

What is an HSV?

A

Highly selective vagotomy

Vagus supply denervated where it supplies the lower oesophagus and stomach

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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

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25
Q

What are the indications for surgery for obesity?

A 
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
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26
Q

What are the main mechanisms underlying surgery for obesity?

A

Restrict calorie intake by reducing stomach capacity

Reduced length of functional small bowel to reduce absorption

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27
Q

How does gastric banding work?

A

Creates a pre-stomach pouch by placing a band around the top of the stomach
Can adjust the band to alter restriction

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28
Q

What are the potential complications of gastric band surgery?

A

Pouch enlargement
Band slip/erosion
Port infection or breakage

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29
Q

How does gastric bypass surgery work?

A

Jejunum attached to small stomach pouch
Allows food to bypass distal stomach, duodenum and proximal jejunum
Restriction and malabsorption

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30
Q

What are the potential complications of gastric bypass surgery?

A 
Micronutrient deficiency
Dumping syndrome
Wound infection
Hernias
Malabsorption
Diarrhoea
Mortality 0.5%
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31
Q

What is the incidence of pancreatic cancer?

A

8 per 100,000 females

10 per 100,000 males

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32
Q

What is the incidence of oesophageal cancer?

A

8 per 100,000 females

16 per 100,000 males

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33
Q

What are the risk factors for oesophageal cancer?

A 
Obesity
Barrett's oesophagus
Reflux
Smoking
Alcohol
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34
Q

What is the type of cancer found more commonly in the distal oesophagus?

A

Adenocarcinoma

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35
Q

What is the type of cancer found more commonly in the proximal oesophagus?

A

Squamous cell carcinoma

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36
Q

How does oesophageal cancer present?

A 
Dysphagia
Weight loss
Regurgitation
Retrosternal chest pain
Hoarseness of voice
Cough
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37
Q

What are the risk factors for stomach cancer?

A

H.pylori infection

Smoking

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38
Q

What are the common presenting symptoms of gastric cancer?

A

Non-specific: dyspepsia, weight loss, vomiting, dysphagia, anaemia, epigastric pain

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39
Q

Where does gastric cancer commonly spread?

A

Ovaries

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40
Q

What signs suggest gastric cancer is incurable?

A 
Epigastric mass
Hepatomegaly
Jaundice
Ascites
Large left supraclavicular mode
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41
Q

How do bile duct and gallbladder cancers present?

A 
Obstructive jaundice
Pruritis
Abdominal pain
Weight loss
Anorexia
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42
Q

What is the most common cancer in the liver?

A

Mets from colorectal cancer

Rarely kidney or endocrine mets

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43
Q

What proportion of liver resections are for primary liver cancer?

A

10%

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44
Q

What are the different types of pancreatectomy?

A

Whipple
Distal
Total

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45
Q

What are the diagnostic indications for upper GI endoscopy?

A 
Haematemesis
New dyspepsia >55yo
Gastric biopsy ?cancer
Duodenal biopsy
Persistent vomiting
Iron deficiency
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46
Q

Why do high levels of unconjugated bilirubin make you ill?

A

It crosses the BBB

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47
Q

Where does unconjugated bilirubin come from?

A

Mainly moron RBC breakdown

Some from myoglobin

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48
Q

Where are bile salts reabsorbed?

A

Terminal ileum

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49
Q

What are the functions of bile?

A

Helps absorb fats
Neutralises chyme
Excretes cholesterol

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50
Q

What are the causes of pre-hepatic jaundice?

A

Haemolysis eg spherocytosis

Gilbert’s syndrome - defect in liver uptake of unconjugated bilirubin

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51
Q

What are the blood test findings in Gilbert’s syndrome?

A

Raised bilirubin

Normal LFTs

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52
Q

What are the causes of hepatic jaundice?

A

Viral or alcoholic hepatitis
Drug induced eg amoxicillin and flucloxacillin
Cirrhosis

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53
Q

What is surgical jaundice?

A

Obstructive (post-hepatic) jaundice

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54
Q

What is the most common cause of obstructive jaundice?

A

Gallstones

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55
Q

What are the other causes of obstructive jaundice?

A

Malignant
Benign eg biliary stricture
Autoimmune eg sclerosing Cholangitis
Congenital

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56
Q

What does a rapid rise in bilirubin suggest?

A

Malignancy

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57
Q

What malignancies can cause obstructive jaundice?

A 
Hilar cholangiocarcinoma
Gallbladder
Distal cholangiocarcinoma
Ampullary tumours
Pancreatic
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58
Q

What do you need to ask about in a history of obstructive jaundice?

A 
Abdominal pain
Fever
Itching
Alcohol
Drugs
Weight loss
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59
Q

What are you looking for on physical examination of someone with jaundice?

A 
Masses
Hepato/Splenomegaly
Stigmata of liver disease
Ascites
Caput medusa
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60
Q

What do raised ALP and bilirubin suggest?

A

Obstructive cause of jaundice

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61
Q

How do you manage stones in the common bile duct?

A

ERCP

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62
Q

What is Courvoisier’s law?

A

In the presence of jaundice, a palpable gallbladder is unlikely to be gallstones

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63
Q

What are the risk factors for gallstones?

A 
Fair
Fat
Female
Fertile
Forty
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64
Q

What are the most common type of gallstones?

A

Mixed (cholesterol and pigment)

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65
Q

What is biliary colic?

A

Pain in the absence of infection
Most common presentation of gallstones
Transient obstruction of cystic duct by gallstone

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66
Q

How does biliary colic present?

A

RUQ pain, colicky in nature
Abrupt onset, ?exacerbated by fatty foods
Associated with nausea and vomiting
No raised WCC or pyrexia

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67
Q

How is biliary colic managed?

A

Try not to admit

Bring back as day case for lap chole

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68
Q

What is acute chole cystitis?

A

Obstruction of cystic duct by gallstone

Leading to inflammation and involvement of parietal peritoneum

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69
Q

What is Murphy’s sign?

A

Deep breath in - liver moves down - you can feel gallbladder

If this causes pain, indicates gallbladder is inflamed (acute cholecystitis)

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70
Q

What are the notable biochemical abnormalities in acute cholecystitis?

A

WCC raised

Mildly raised ALP

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71
Q

What is the investigation of choice for gallstones?

A

Ultrasound: 90% sensitive and specific

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72
Q

Why should you check amylase when gallstones are suspected?

A

Not uncommon to have cholecystitis and pancreatitis at the me time

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73
Q

What constitutes evidence of stones in the common bile duct?

A

Visible jaundice
Intrahepatic dilatation
Cystic duct dilated

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74
Q

What is ERCP?

A

Endoscopic retrograde cholangiopancreatography

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75
Q

What drug therapy may be used to treat small gallstones?

A

Chenodeoxycholic acid

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76
Q

What is the likely diagnosis with RUQ pain, fever and jaundice?

A

Cholangitis

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77
Q

What is the likely diagnosis with RUQ pain and a fever?

A

Acute cholecystitis

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78
Q

What are the indications for lap chole?

A

Symptomatic gallstone disease

Asymptomatic gallstones with a reasonable likelihood of future complications

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79
Q

What are the local complications of gallstones?

A 
Mucocoele
Empyema
Gangrene or perforation
Fistula
Mirizzi syndrome
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80
Q

How does a gallstone lead to development of a mucocoele?

A

Stone blocked in duct causes stasis of fluid in gallbladder
Leads to infection
Can lead to gallbladder necrosis

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81
Q

What is gallstone ileus?

A

Fistula allows gallstone to pass from gallbladder into colon

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82
Q

What is Charcot’s triad?

A

Fever
RUQ pain
Jaundice

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83
Q

What is choledocholithiasis?

A

Stones within common bile duct

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84
Q

What are the indications for ERCP?

A

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

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85
Q

What can ERCP show?

A

Stricture
Tumour
Gallstones

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86
Q

What is the purpose of stenting in ERCP?

A

To widen common bile duct if it is narrowed or blocked

Allows bile into duodenum

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87
Q

What are the complications of ERCP?

A

Pancreatitis
Gut perforation, bleeding, infection
Chest infection

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88
Q

What forms the common bile duct?

A

Common hepatic duct + cystic duct + pancreatic duct

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89
Q

Where does the common bile duct enter the duodenum?

A

Ampulla of Vater

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90
Q

Where is the ampulla of Vater?

A

Posterior-medial wall of duodenum

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91
Q

What are the functions of the pancreas?

A

Secretes proemzymes and bicarbonate

Endocrine function - insulin and glucagon

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92
Q

How does acute pancreatitis present?

A

Epigastric pain - constant, max intensity several hours after onset
Radiates to back
Aggravated by movement and relieved by sitting up
Associated nausea and vomiting

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93
Q

What are the causes of acute pancreatitis?

A

GET SMASHED

Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hyperlipidaemia, ERCP, Drugs

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94
Q

What are the signs of acute pancreatitis?

A 
Epigastric tenderness
Abdominal distension
Fever and tachycardia
Grey-Turners sign
Jaundice
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95
Q

What is Grey-Turner’s sign?

A

Bruising in flank

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96
Q

What are the differential diagnoses of acute pancreatitis?

A 
Perforated duodenal ulcer
Mesenteric infarction
MI
AAA
Cholecystitis/Cholangitis
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97
Q

Name a grading scale used for acute pancreatitis

A

Glasgow

Ranson

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98
Q

How do you manage mild acute pancreatitis?

A 
IV fluids
Catheterise
Correct electrolytes
Hourly obs
Identify and treat precipitating cause once settled
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99
Q

How do you treat severe pancreatitis?

A

Antibiotics
Consider escalation
Feed them if tolerated - catabolic state!

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100
Q

What are the systemic complications of acute pancreatitis?

A

Shock (GI fluid loss)
Pulmonary insufficiency
Metabolic: low calcium, magnesium and albumin
DIC
Systemic cytokine activation: multiple organ dysfunction syndrome

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101
Q

Why is there a 2nd peak in mortality after 2-4 weeks in acute pancreatitis?

A

Local complications mainly due to pancreatic necrosis

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102
Q

How is pancreatic necrosis manages?

A

Sterile necrosis managed conservatively

Infected necrosis needs debridement

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103
Q

What are the local complications of pancreatitis?

A

Necrosis
Abscess
Pancreatic pseudo cyst
Ascites, fistulae, duct stricture, haemorrhage

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104
Q

Define chronic pancreatitis

A

Recurrent or persistent abdominal pain with evidence of exo/endocrine pancreatic insufficiency

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105
Q

What are the causes of chronic pancreatitis?

A 
Alcohol, tobacco
Idiopathic
Genetic
Autoimmune
Recurrent and severe acute pancreatitis
Obstructive
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106
Q

How does chronic pancreatitis present?

A

Recurrent epigastric pain radiating to back
Anorexia and weight loss
Steatorrhea and malabsorption
Diabetes

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107
Q

How is chronic pancreatitis diagnosed?

A

Clinical history and findings
Radiological evidence of calcification, fibrosis of gland
Analysis of endocrine and exocrine function

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108
Q

How do you treat chronic pancreatitis?

A

Creon with each meal
Opiate analgesia
Give up alcohol
Diabetic control

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109
Q

What surgery may be used for chronic pancreatitis?

A

Resection - remove abnormal part of pancreas

Drainage - small bowel anastomosed to pancreatic duct, or core out pancreatic head

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110
Q

What proportion of cases of acute pancreatitis are cause by gallstones or alcohol?

A

80%

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111
Q

How is serum amylase relevant to acute pancreatitis?

A

X3 upper limit is diagnostic

NOT prognostic - use scoring systems instead

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112
Q

What is an acute abdomen?

A

Recent or sudden onset unexpected signs/symptoms including abdominal pain

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113
Q

What are the causes of visceral pain?

A

Stimulation of receptors in smooth muscle, eg
Ischaemia
Distension/stretching
Tension

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114
Q

Why is visceral pain poorly localised?

A

Conducted by autonomic nerves

Poorly localised in midline, following embryological origin

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115
Q

What are the associated features of visceral pain?

A

Malaise
Nausea
Vomiting
Sweating

116
Q

What is somatic pain?

A

Stimulation of pain receptors in parietal peritoneum

117
Q

Why is somatic pain well-localised?

A

Conducted by segmental somatic nerves

118
Q

What is referred pain?

A

Due to common central neural pathways in the spinal cord, where somatic nerves and visceral organs share pathways

119
Q

What causes the majority of ‘acute abdomens’?

A

Nonspecific ie tummy ache!

34% of presentations

120
Q

What is the second most common cause of an acute abdomen?

A

Acute appendicitis

121
Q

What does sudden onset abdominal pain suggest?

A

Perforation

Rupture

122
Q

Name 3 colic syndromes

A

Biliary colic
Ureteric colic
Small bowel obstruction

123
Q

What does gradual onset abdominal pain suggest?

A

Inflammatory conditions
Obstructive processes
Other mechanical processes

124
Q

What features may be associated with an acute abdomen?

A 
Appetite
Nausea and vomiting
Distension
Altered bowel habit
Weight loss
125
Q

What other systems do you need to ask about with an acute abdominal presentation?

A

Gynae: LMP, PV discharge
Urinary: frequency, urgency, pain, haematuria

126
Q

What other medical conditions may present as an acute abdomen?

A

MI
Pneumonia or pleurisy
Herpes zoster
Diabetic ketoacidosis

127
Q

What features of an acute abdomen suggest malignancy?

A 
Intermittent pain of over 48h duration
Altered bowel habit
Distension
Mass
Weight loss
128
Q

What features suggest intestinal obstruction?

A 
Colicky severe pain
No aggravating factors
Vomiting/constipation (depending on level of obstruction)
Previous surgery
Distension
High pitched bowel sounds
129
Q

What features suggest a perforated viscus?

A 
Sudden onset pain
Constant severe pain
Aggravated by movement or coughing
Diffuse tenderness
Silent rigid abdomen
130
Q

What features suggest an AAA?

A

Sudden onset central abdominal pain
Collapsed
Hypotensive

131
Q

Where should you start on palpation of the abdomen?

A

Away from the site of pain!

132
Q

What does guarding suggest?

A

Peritonitis

133
Q

What bedside investigations would you perform for an acute abdomen?

A 
BMs
Urinalysis
Pregnancy test
ECG
Obs
134
Q

What laboratory investigations would you order for an acute abdomen?

A

FBC, UEs, serum amylase

LFTs, ABG, clotting, group&save

135
Q

How do you manage an acute abdomen?

A 
NBM
IV fluids
Obs
Thromboprophylaxis
Analgesia/antiemetic
136
Q

What is the lifetime prevalence of acute appendicitis?

A
  1. 6% men

6. 7% women

137
Q

What are the causes of acute appendicitis?

A 
Faecolith
Foreign body
Tumour
Worms
Trauma
Lymphadenitis
138
Q

What is the pathological process in acute appendicitis?

A

Blockage of outflow (eg by swollen lymph glands caused by inflammation)
Stasis
Infection

139
Q

How long after onset of symptoms does perforation occur in acute appendicitis?

A

24 to 36 hours

140
Q

Why is a perforated appendix bad?

A

Leads to peritonitis

141
Q

What is the classic presentation of acute appendicitis?

A

Vague peri umbilical pain
Localising to right iliac fossa
Nausea, vomiting, anorexia
Guarding in peritonitis

142
Q

What other conditions can mimic appendicitis?

A 
Ectopic pregnancy
Pancreatitis
Gastroenteritis
Ulcerative colitis
UTI
143
Q

What is rebound tenderness?

A

Pain on removal of pressure

Indicates peritonitis

144
Q

Where is McBurney’s point?

A

1/3 between ASIS and umbilicus

145
Q

What is the psoas sign?

A

Pain on hip flexion

Inflamed caecum/appendix irritates psoas muscle

146
Q

Why is ultrasound done in suspected acute appendicitis?

A

Doesn’t pick up appendicitis, but would show other pathologies eg ovarian cyst or gastroenteritis

147
Q

What imaging does show acute appendicitis?

A

CT abdomen

148
Q

How is WCC affected by appendicitis?

A

May be raised, but can still be normal

149
Q

What are the complications of acute appendicitis?

A

Infections of wound or pelvic abscess
Bleeding
Fistulation

150
Q

How do you manage a well patient with acute appendicitis?

A 
Observe
Analgesia
NBM
?antibiotics
Re-assessment
151
Q

When is surgery indicated for acute appendicitis?

A

Peritonitis

Unwell

152
Q

What are the causes of upper GI bleeding?

A

Oesophagus: tumour, MWT, varices
Stomach: tumour, ulcer, erosions
Duodenum: ulcers, haemobilia

153
Q

What small bowel pathology can cause bleeding?

A

Tumours
Ulceration
IBD
Meckel’s diverticulum

154
Q

What large bowel pathologies can cause bleeding?

A 
Tumours
Diverticular disease
Radiation damage
AV malformation
IBD
155
Q

What anal pathologies can cause bleeding?

A

Piles

Varices

156
Q

How do you manage an upper GI bleed?

A 
Resuscitation/stabilisation of patient
OGD +/- ulcer intervention
PPI + H.pylori eradication
Treatment for varices
Surgery only if above measures fail
157
Q

What are the causes of small amounts of rectal bleeding?

A

Haemorrhoids
Colorectal cancer
Colitis
Vascular is

158
Q

What are the causes of massive rectal bleeding?

A

Colonic diverticular disease

Angiodysplasia

159
Q

How do you manage a PR bleed?

A

Resuscitation: 2 large bore cannulae, IV fluids
Catheterise
Oxygen
Adrenaline - vasoconstriction to stop bleeding
Operative management difficult due to lack of precise site

160
Q

Define shock

A

Inadequate tissue perfusion to meet the metabolic needs of the tissue

161
Q

What are the classes of hypovolaemic shock?

A

1 - less than 15% total blood volume lost
2 - 15-30%
3 - 30-40%
4 - >40%

162
Q

What are the causes of an upper GI perforation?

A

Ulcers

Cancer

163
Q

What are the causes of small bowel perforation?

A

Cancers
Foreign bodies
Obstruction
Trauma

164
Q

What are the causes of large bowel perforation?

A 
Diverticular disease
Cancer
Obstruction
IBD
Iatrogenic
165
Q

How does a perforated bowel present?

A

Abdominal pain
Generalised peritonitis
Hyper-dynamic circulation - tachycardia, pyrexia, flushed
Shocked

166
Q

When is conservative management of bowel perforation used?

A

No generalised sepsis or peritonitis

167
Q

How is bowel perforation managed initially?

A 
Resuscitation - IV fluids
Oxygen
Catheter
IV antibiotics
Analgesia
168
Q

How would bowel perforation be managed conservatively?

A

Antibiotics
Bed rest
PPI for UGI
Radiological drainage where required

169
Q

What is the mortality from faecal peritonitis?

170
Q

What is an ileostomy?

A

Surgical opening constructed by bringing the end/loop of small intestine out onto the surface of the skin

171
Q

What is a colostomy?

A

Healthy end of large intestine drawn through incision in anterior abdominal wall

172
Q

How do you tell the difference between an ileostomy and a colostomy?

A

Ileostomy has a spout

Colostomy flush with skin

173
Q

What are the causes of rectal bleeding?

A 
Diverticulitis
Colorectal cancer
Haemorrhoids
Crohn's or UC
Perinatal disease
Angiodysplasia
174
Q

What bloods would you order for a PR bleed?

A 
FBC
UE
LFT
Clotting
Amylase
CRP
Group&save
175
Q

How does angiodysplasia present?

A

Fresh PR bleed in the elderly

176
Q

What are the causes of colitis?

A

Inflammatory
Infective
Ischaemic
Radiation

177
Q

How does smoking influence inflammatory bowel disease?

A

Protective for UC

Increases risk of Crohn’s

178
Q

Name 3 extra-GI manifestations of inflammatory bowel disease

A

Erythema nodosum
Arthropathy
Uveitis/iritis

179
Q

What area of the GI tract is most commonly affected in Crohn’s?

A

Terminal ileum

180
Q

What is the incidence of ulcerative colitis?

A

10-20 per 100,000 per year

181
Q

What is the peak age of onset for ulcerative colitis?

A

10-40 years

182
Q

What are the symptoms of ulcerative colitis?

A 
Bloody diarrhoea
Abdominal pain
Urgency
Systemic: fever, malaise, weight loss
Extracolonic: joint pain, sore eyes, cutaneous
183
Q

What is the medical treatment for ulcerative colitis?

A

Steroids: topical, oral or IV
5-ASA preparations eg sulfasalazine
Cyclosporine

184
Q

What are the indications for surgery in ulcerative colitis?

A 
Failed medical treatment
Haemorrhage
Perforation
Cancer
Extra-intestinal manifestations
185
Q

How does surgery affect prognosis for ulcerative colitis?

A

It is curative

186
Q

What is the incidence of Crohn’s disease?

A

5-10 per 100,000 per year

187
Q

What is the peak age of onset of Crohn’s disease?

A

2 peaks
15-30
60-80

188
Q

What are the symptoms of Crohn’s disease?

A 
General malaise, anorexia, weight loss
Intermittent diarrhoea
Abdominal pain
Mouth ulcers
Recurrent perianal abscesses
Fistula symptoms
Eye and joint problems
189
Q

What is the medical treatment for Crohn’s disease?

A 
Steroids
ASA preparations
Azathioprine
Methotrexate
Metronidazole
190
Q

What are the indications for surgery in Crohn’s disease?

A 
Failed medical therapy
Fistula +/- abscess
Obstruction secondary to strictures
Cancer
Haemorrhage
Perforation
Growth retardation in children
191
Q

What is the difference between an ileoanal pouch and an ileostomy?

A

Pouch forms a reservoir for storing liquid motion to maintain continence
Small bowel can be connected to the anus

192
Q

What categories of causes are there for intestinal obstruction?

A

Extramural
Intramural
Intraluminal

193
Q

What are the 3 commonest causes of small bowel obstruction?

A

Adhesions
Hernia
Tumour

194
Q

What are adhesions?

A

Bowel obstruction caused by fibrous tissue usually resulting from previous surgery

195
Q

What are the intramural causes of intestinal obstruction?

A

Inflammation
Tumours
Strictures

196
Q

What should you be thinking of in small bowel obstruction with no previous surgery?

197
Q

What are the symptoms of small bowel obstruction?

A

Abdominal pain - colicky at first, more regular and shorter duration than large bowel. Periumbilical pain
Vomiting
Distension
Failure to pass flatus

198
Q

What are the signs of small bowel obstruction?

A 
Tachycardia
Hypotension
Fever
Distension
Look for hernias
Visible peristalsis
Tenderness - indicates imminent perforation
High-pitched, tinkling bowel sounds
199
Q

How do you distinguish between small and large bowel on X-Ray?

A

Small bowel has complete lines across and is more central
SB diameter 2.5cm
LB diameter 5.5-6cm

200
Q

When is surgery indicated for small bowel obstruction?

A 
Non-adhesion all obstruction
Perforation evidence on imaging
Fever
Marked tenderness indicating peritonitis
Failure of resolution of adhesion all obstruction
201
Q

What are the three most common causes of large bowel obstruction?

A

Colorectal carcinoma
Diverticular disease
Volvulus

202
Q

How does large bowel obstruction present differently to small bowel obstruction?

A

No vomiting if ileocaecal valve competent
Interval between bouts of pain longer
Rectal exam may reveal a mass

203
Q

What radiological investigations are used for bowel obstruction?

A

AXR
CXR (erect)
CT scan

204
Q

Definitive management for bowel obstruction is surgery, with which 2 exceptions?

A

Adhesions with no signs of peritonitis

Volvulus with no signs of peritonitis

205
Q

Where do the majority of colorectal cancers occur?

A

Rectum (27%)

206
Q

How does colon cancer present?

A 
Vague ill health
Acute or chronic obstruction
Perforation
Bleeding
Anaemia
Tenesmus
207
Q

Where does colon cancer commonly spread to?

A

Direct - up to 2 cm within bowel wall
Lymphatic
Blood - liver via portal vein

208
Q

How does rectal cancer present?

A 
Bleeding
Change in bowel habit (constipation or diarrhoea)
Urgency
Incomplete evacuation
Wet wind
Tenesmus
Colic
209
Q

What is a more worrying change in bowel habit and why?

A

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
Q

What is Duke’s A?

A

Tumour confined to muscle

94% 5-year survival

211
Q

What is duke’s B?

A

Tumour spread through muscle

76% 5-year survival

212
Q

What is duke’s C?

A

Spread into lymph nodes

32% 5-year survival

213
Q

What is duke’s D?

A

Distant metastasis

214
Q

What are the surgical options for rectal cancer?

A

Anterior resection if >5 cm from anus

Abdomino-perineal resection with end colostomy if within 5cm of anus

215
Q

What are the rules of tumour resection?

A

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
Q

What is the 5-year survival rate of colorectal cancer that has metastasised?

217
Q

How is radiotherapy used in rectal cancer?

A

Pre-operative

Reduces local recurrence rate

218
Q

What vessel is most commonly affected in mesenteric ischaemia?

A

Superior mesenteric artery

219
Q

What is the most common cause of mesenteric ischaemia?

A

Thrombosis

220
Q

What is the classic triad of features of acute mesenteric ischaemia?

A

Acute severe abdominal pain: constant, central/RIF
No abdominal signs
Rapid hypovolaemia leading to shock

221
Q

What are the life-threatening complications of acute mesenteric ischaemia?

A

Septic peritonitis

Progression of SIRS into MODS

222
Q

How do you manage acute mesenteric ischaemia?

A

IV fluid resus
ABx (gentamicin and metronidazole)
Heparin
Surgery to remove necrosis bowel

223
Q

What is chronic mesenteric ischaemia also known as?

A

Intestinal angina

224
Q

What are the features of chronic mesenteric ischaemia?

A 
Severe colicky post-prandial abdominal pain (gut claudication)
Weight loss
Upper abdominal bruit
PR bleed
Malabsorption
Nausea and vomiting
History of vascular disease
225
Q

What is chronic colonic ischaemia?

A

Ischaemic colitis

Low flow in Inferior Mesenteric Artery territory

226
Q

What are the features of ischaemic colitis?

A

Lower left-sided abdo pain plus bloody diarrhoea

227
Q

What is a strawberry naevus?

A

Cavernous haemangioma

228
Q

How do you treat strawberry naevus?

A

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
Q

What is a capillary haemangioma otherwise known as?

A

Port-wine stain

230
Q

What causes spider naevi?

A

High levels of oestrogen

231
Q

Why may spider naevi occur in cirrhosis of the liver?

A

Oestrogen normally broken down in liver

Cirrhosis in men causes gynaecomastia and testicular atrophy too

232
Q

Why may obese men appear feminine?

A

Oestrogen precursors are produced in the adrenal cortex then converted in peripheral fat

233
Q

What is a papilloma?

A

Abnormal growth within the skin

234
Q

What are the different types of papilloma?

A

Smooth, pedunculated
Sessile
Pigmented

235
Q

In what condition do you get sessile papillomas?

236
Q

What are the 6Ss of examining a lump?

A 
Site
Size
Shape
Smoothness
Surface
Surroundings
237
Q

What lumps are intradermal?

A

Sebaceous cyst
Abscess
Dermoid cyst
Granulomas

238
Q

What are the differential diagnoses for a subcutaneous lump?

A

Lipoma
Ganglion
Neuroma
Lymph node

239
Q

What is transillumination?

A

Shine a light through a lump

If it glows red this is transilluminable eg hydrocoele

240
Q

What is a neurofibroma?

A

Benign nerve sheath tumour in peripheral nervous system

241
Q

What is tennell’s sign?

A

Tap on lump/area and it causes tingling

242
Q

What is a lipoma?

A

Benign lump beneath the skin, in subcutaneous fat

243
Q

What is fluctuancy?

A

Only seen in cysts

Moveable and compressible

244
Q

What is the pathology leading to formation of a ganglion?

A

Myxomatous degeneration of joint capsules, forming a jelly-like substance

245
Q

What do sebaceous cysts contain?

246
Q

Where can sebaceous cysts occur?

A

Anywhere you have hair!

247
Q

Where do dermoid cysts occur and why?

A

Midline of face
Lateral canthus
Behind ear
Arise from cystic changes in epithelial remnants at lines of embryological fusion

248
Q

What is the differential diagnosis for a dermoid cyst?

A

Thyroglossal cyst - this would move up when the tongue is poked out

249
Q

What are implantation dermoid cysts?

A

Skin beneath skin produced hair and leads to a cyst

Commonest in fingers eg manual workers

250
Q

What is a fistula?

A

Abnormal connection between 2 epithelial surfaces

251
Q

What is a pilonidal sinus?

A

Nest of hairs beneath the skin
Hairy bottom - keep sitting on it and pushing hair beneath the skin
Can cause continual infections

252
Q

Where do keratocanthomas commonly occur?

253
Q

What is a keloid scar?

A

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
Q

What is erythema ab igne?

A

Holding hot water bottle against abdomen

Common in alcoholics

255
Q

What is the gate theory of pain?

A

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
Q

What are the 5 different types of ulcers?

A 
Sloping
Punched-out
Undermined
Rolled
Everted
257
Q

Give an example of a cause of a punched-out ulcer

A

Trophic eg diabetes due to lack of nerve supply

258
Q

Give an example of a sloping ulcer

A

Healing venous ulcer

259
Q

What are boils?

A

Furuncles

Abscesses involving a hair follicle and associated gland

260
Q

What is hidradenitis suppurativa?

A

Continuous infection in armpit

261
Q

Define hernia

A

The protrusion of an organ through its containing wall

262
Q

What are the basic features of all hernias?

A

Occur at a weak spot
May reduce on lying down, or with direct pressure
May have an expansile cough impulse

263
Q

Name 5 common hernias

A 
Inguinal
Femoral
Incisional
Epigastric
Umbilical
264
Q

What is the clinical significance of the lymphatic drainage of the testicles?

A

Drain to paraaortic nodes so show no lymphadenopathy in malignancy

265
Q

Where does a direct inguinal hernia protrude?

A

Medial to inferior epigastric artery

Outside spermatic cord

266
Q

Where is the femoral canal?

A

Below and lateral to the pubic tubercle

267
Q

Where is the mid-inguinal point?

A

Midway between ASIS and pubic symphysis

268
Q

What is the function of the femoral canal?

A

Allow expansion of femoral vein

Eg on standing

269
Q

Why is a femoral hernia potentially more dangerous than other hernias?

A 
Lacunar ligament (medial to canal) is very tough
Femoral hernia much more likely to strangulate and kill
270
Q

What are the 4 benign perianal conditions?

A

Piles
Perianal sepsis (fistula/abscess)
Fissure
Pilonidal sinus

271
Q

How are piles graded?

A

1-4 depending on degree of prolapse

272
Q

What are the symptoms of piles?

A

Bright red bleeding

Prolapse

273
Q

What are grade 1 piles?

A

Only bleeding, no prolapse

274
Q

What are grade 2 piles?

A

Prolapse only on defecation

275
Q

What are grade 3 piles?

A

Prolapse, but can push it back up

276
Q

What are grade 4 piles?

A

Permanent prolapse

277
Q

How do you confirm the presence of piles?

A

Proctoscopy

278
Q

What are the conservative measures for piles?

A

High fibre diet
Plenty of fluids
Avoid straining

279
Q

What are the medical interventions for piles?

A

Creams

Stool softeners eg fybogel

280
Q

What are the surgical options for piles?

A

Banding
Injection
HALO
Haemorrhoidectomy and put stitches in piles

281
Q

What are the symptoms of anal fissures?

A

Anal pain
Bit of bleeding
Pain after defecation lasting up to several hours

282
Q

What is the classic presentation of an anal fissure?

A

Constipation for a while
Then passing a hard stool
Tears the ectoderm and creates a fissure

283
Q

What are the conservative measures for an anal fissure?

A

Prevent constipation

Creams: GTN or diltiazem

284
Q

Which patients are at increased risk of perianal sepsis?

A

Diabetes
Immunocompromised
Older people
Obese people

285
Q

What can chronic perianal sepsis lead to?

A

Fistula formation

286
Q

What is the cryptoglandular theory of anal abscess formation?

A

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
Q

What is a pilonidal sinus?

A

Nest of hairs

Pits in midline

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