General Surgery Flashcards
What are the therapeutic indications for upper GI endoscopy?
Treat bleeding lesions
Variceal banding and sclerotherapy
Stricture dilatation
Stent insertion
What are the diagnostic indications for colonoscopy?
Rectal bleeding Iron deficiency anaemia Persistent diarrhoea Biopsy lesion seen on barium enema Assess/suspicion of IBD Colon cancer surveillance
What are the therapeutic indications for colonoscopy?
Haemostasis Bleeding angiodysplasia lesion Volvulus untwisting Pseudo-obstruction Polypectomy
What sedatives can be used in endoscopy?
Medazolam to remain conscious
Propofol for GA
What is duodenal biopsy used for?
Gold standard diagnosis of Coeliac disease
How far can a sigmoidoscopy view?
Rectum and sigmoid colon up to splenic flexure
What are the dietary requirements to prepare for colonoscopy?
Low residue diet 1-2 days preop
Clear fluids but no solid food after lunch day before
What bowel prep is used for colonoscopy?
Sodium picosulfate morning and afternoon day before
What are the potential complications of colonoscopy?
Abdominal discomfort
Incomplete examination
Haemorrhage after biopsy or Polypectomy
Perforation
How does a carcinoma differ in appearance to a polyp?
Carcinoma is irregular in shape/colour and is larger and more aggressive
What does active ulcerative colitis look like on colonoscopy?
Mucosa red and inflamed
Friable - bleeds on touch
Severe: mucopurulent exudate, mucosal ulceration and bleeding
What are the conservative measures for peptic disorders?
No spicy or acidic food
Reduce alcohol intake
Smoking cessation
Avoid certain meds eg NSAIDs
What medications are used to treat peptic disorders?
Antacids
Alginates
H2 receptor antagonist
PPI
What is triple therapy for peptic ulcers?
PPI
2 antibiotics
What does a partial Gastrectomy involve?
Remove affected part of stomach
Anastomose remnant of stomach with either the duodenum or an ileal loop
What are the long-term side effects of a partial gastrectomy?
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
What is dumping syndrome?
Fainting and swearing after eating
Food with high osmotic potential dumped in jejunum, causing oligaemia from rapid fluid shift
Helped by eating less glucose
Why may vitamin B12 deficiency happen after gastric surgery?
No intrinsic factor production
What is a Billroth I procedure?
Partial Gastrectomy with simple gastroduodenal re-anastomosis
What is a Billroth II procedure?
Partial gastrectomy with gastrojejunal anastomosis
What is a Roux-en-Y procedure?
Anastomosis between stomach and part of small bowel distal to the cut end
When is surgery indicated for peptic ulcers?
Haemorrhage
Perforation
Pyloric stenosis
What is an HSV?
Highly selective vagotomy
Vagus supply denervated where it supplies the lower oesophagus and stomach
What is laparoscopic fundoplication?
Defect in diaphragm repaired by tightening the crura
Prevent reflux by wrapping fundus of stomach around lower oesophageal sphincter
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
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
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
What are the potential complications of gastric band surgery?
Pouch enlargement
Band slip/erosion
Port infection or breakage
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
What are the potential complications of gastric bypass surgery?
Micronutrient deficiency Dumping syndrome Wound infection Hernias Malabsorption Diarrhoea Mortality 0.5%
What is the incidence of pancreatic cancer?
8 per 100,000 females
10 per 100,000 males
What is the incidence of oesophageal cancer?
8 per 100,000 females
16 per 100,000 males
What are the risk factors for oesophageal cancer?
Obesity Barrett's oesophagus Reflux Smoking Alcohol
What is the type of cancer found more commonly in the distal oesophagus?
Adenocarcinoma
What is the type of cancer found more commonly in the proximal oesophagus?
Squamous cell carcinoma
How does oesophageal cancer present?
Dysphagia Weight loss Regurgitation Retrosternal chest pain Hoarseness of voice Cough
What are the risk factors for stomach cancer?
H.pylori infection
Smoking
What are the common presenting symptoms of gastric cancer?
Non-specific: dyspepsia, weight loss, vomiting, dysphagia, anaemia, epigastric pain
Where does gastric cancer commonly spread?
Ovaries
What signs suggest gastric cancer is incurable?
Epigastric mass Hepatomegaly Jaundice Ascites Large left supraclavicular mode
How do bile duct and gallbladder cancers present?
Obstructive jaundice Pruritis Abdominal pain Weight loss Anorexia
What is the most common cancer in the liver?
Mets from colorectal cancer
Rarely kidney or endocrine mets
What proportion of liver resections are for primary liver cancer?
10%
What are the different types of pancreatectomy?
Whipple
Distal
Total
What are the diagnostic indications for upper GI endoscopy?
Haematemesis New dyspepsia >55yo Gastric biopsy ?cancer Duodenal biopsy Persistent vomiting Iron deficiency
Why do high levels of unconjugated bilirubin make you ill?
It crosses the BBB
Where does unconjugated bilirubin come from?
Mainly moron RBC breakdown
Some from myoglobin
Where are bile salts reabsorbed?
Terminal ileum
What are the functions of bile?
Helps absorb fats
Neutralises chyme
Excretes cholesterol
What are the causes of pre-hepatic jaundice?
Haemolysis eg spherocytosis
Gilbert’s syndrome - defect in liver uptake of unconjugated bilirubin
What are the blood test findings in Gilbert’s syndrome?
Raised bilirubin
Normal LFTs
What are the causes of hepatic jaundice?
Viral or alcoholic hepatitis
Drug induced eg amoxicillin and flucloxacillin
Cirrhosis
What is surgical jaundice?
Obstructive (post-hepatic) jaundice
What is the most common cause of obstructive jaundice?
Gallstones
What are the other causes of obstructive jaundice?
Malignant
Benign eg biliary stricture
Autoimmune eg sclerosing Cholangitis
Congenital
What does a rapid rise in bilirubin suggest?
Malignancy
What malignancies can cause obstructive jaundice?
Hilar cholangiocarcinoma Gallbladder Distal cholangiocarcinoma Ampullary tumours Pancreatic
What do you need to ask about in a history of obstructive jaundice?
Abdominal pain Fever Itching Alcohol Drugs Weight loss
What are you looking for on physical examination of someone with jaundice?
Masses Hepato/Splenomegaly Stigmata of liver disease Ascites Caput medusa
What do raised ALP and bilirubin suggest?
Obstructive cause of jaundice
How do you manage stones in the common bile duct?
ERCP
What is Courvoisier’s law?
In the presence of jaundice, a palpable gallbladder is unlikely to be gallstones
What are the risk factors for gallstones?
Fair Fat Female Fertile Forty
What are the most common type of gallstones?
Mixed (cholesterol and pigment)
What is biliary colic?
Pain in the absence of infection
Most common presentation of gallstones
Transient obstruction of cystic duct by gallstone
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
How is biliary colic managed?
Try not to admit
Bring back as day case for lap chole
What is acute chole cystitis?
Obstruction of cystic duct by gallstone
Leading to inflammation and involvement of parietal peritoneum
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)
What are the notable biochemical abnormalities in acute cholecystitis?
WCC raised
Mildly raised ALP
What is the investigation of choice for gallstones?
Ultrasound: 90% sensitive and specific
Why should you check amylase when gallstones are suspected?
Not uncommon to have cholecystitis and pancreatitis at the me time
What constitutes evidence of stones in the common bile duct?
Visible jaundice
Intrahepatic dilatation
Cystic duct dilated
What is ERCP?
Endoscopic retrograde cholangiopancreatography
What drug therapy may be used to treat small gallstones?
Chenodeoxycholic acid
What is the likely diagnosis with RUQ pain, fever and jaundice?
Cholangitis
What is the likely diagnosis with RUQ pain and a fever?
Acute cholecystitis
What are the indications for lap chole?
Symptomatic gallstone disease
Asymptomatic gallstones with a reasonable likelihood of future complications
What are the local complications of gallstones?
Mucocoele Empyema Gangrene or perforation Fistula Mirizzi syndrome
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
What is gallstone ileus?
Fistula allows gallstone to pass from gallbladder into colon
What is Charcot’s triad?
Fever
RUQ pain
Jaundice
What is choledocholithiasis?
Stones within common bile duct
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
What can ERCP show?
Stricture
Tumour
Gallstones
What is the purpose of stenting in ERCP?
To widen common bile duct if it is narrowed or blocked
Allows bile into duodenum
What are the complications of ERCP?
Pancreatitis
Gut perforation, bleeding, infection
Chest infection
What forms the common bile duct?
Common hepatic duct + cystic duct + pancreatic duct
Where does the common bile duct enter the duodenum?
Ampulla of Vater
Where is the ampulla of Vater?
Posterior-medial wall of duodenum
What are the functions of the pancreas?
Secretes proemzymes and bicarbonate
Endocrine function - insulin and glucagon
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
What are the causes of acute pancreatitis?
GET SMASHED
Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hyperlipidaemia, ERCP, Drugs
What are the signs of acute pancreatitis?
Epigastric tenderness Abdominal distension Fever and tachycardia Grey-Turners sign Jaundice
What is Grey-Turner’s sign?
Bruising in flank
What are the differential diagnoses of acute pancreatitis?
Perforated duodenal ulcer Mesenteric infarction MI AAA Cholecystitis/Cholangitis
Name a grading scale used for acute pancreatitis
Glasgow
Ranson
How do you manage mild acute pancreatitis?
IV fluids Catheterise Correct electrolytes Hourly obs Identify and treat precipitating cause once settled
How do you treat severe pancreatitis?
Antibiotics
Consider escalation
Feed them if tolerated - catabolic state!
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
Why is there a 2nd peak in mortality after 2-4 weeks in acute pancreatitis?
Local complications mainly due to pancreatic necrosis
How is pancreatic necrosis manages?
Sterile necrosis managed conservatively
Infected necrosis needs debridement
What are the local complications of pancreatitis?
Necrosis
Abscess
Pancreatic pseudo cyst
Ascites, fistulae, duct stricture, haemorrhage
Define chronic pancreatitis
Recurrent or persistent abdominal pain with evidence of exo/endocrine pancreatic insufficiency
What are the causes of chronic pancreatitis?
Alcohol, tobacco Idiopathic Genetic Autoimmune Recurrent and severe acute pancreatitis Obstructive
How does chronic pancreatitis present?
Recurrent epigastric pain radiating to back
Anorexia and weight loss
Steatorrhea and malabsorption
Diabetes
How is chronic pancreatitis diagnosed?
Clinical history and findings
Radiological evidence of calcification, fibrosis of gland
Analysis of endocrine and exocrine function
How do you treat chronic pancreatitis?
Creon with each meal
Opiate analgesia
Give up alcohol
Diabetic control
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
What proportion of cases of acute pancreatitis are cause by gallstones or alcohol?
80%
How is serum amylase relevant to acute pancreatitis?
X3 upper limit is diagnostic
NOT prognostic - use scoring systems instead
What is an acute abdomen?
Recent or sudden onset unexpected signs/symptoms including abdominal pain
What are the causes of visceral pain?
Stimulation of receptors in smooth muscle, eg
Ischaemia
Distension/stretching
Tension
Why is visceral pain poorly localised?
Conducted by autonomic nerves
Poorly localised in midline, following embryological origin