General Surgery Flashcards
1
Q
Management of appendicitis
A
- Admit patient 2. IV cannula and send bloods 3. Correct fluid and electrolyte disturbance 4. Call surgical registrar 5. Appendectomy 6. Antibiotic coverage
2
Q
Management of:
A) Follicular + papillary carcinoma
B) Medullary carcinoma
C) Thyroid lymphoma
D) Anaplastic carcinoma
A
A) Total thyroidectomy with local removal of involved lymph nodes + adjuvant radioactive iodine
B) Total thyroidectomy + central lymph node dissection with lateral neck dissection and mediastinal clearance for node positive patients (does not respond to radioiodine ablation)
C) Biopsy for confirmation of diagnosis + external beam radiotherapy + chemotherapy
D) NO SURGERY given 5 year survival rate <1%
3
Q
Management of acute cholecystitis?
A
- Admit patient
- Stabilise: NBM, NGT, analgesia, fluids +/- antiemetics
- Antibiotics: Gentamicin 4-5mg/kg 24 hourly + amoxy/ampicillin 2g IV 6 hourly
- If gentamicin is contraindicated, use:
- Ceftriaxone 1g IV daily
- Piperacillin + tazobactam 4+0.5g IV 8 hourly
- Surgical prophylaxis: cephazolin 2g IV within 60 minutes before surgical incision
- If gentamicin is contraindicated, use:
- Cholecystectomy
- Intraoperative cholangiogram (IOC) – indications: clarify bile duct anatomy, obstructive jaundice, history of biliary pancreatitis, small stones in gallbladder with a wide cystic duct (>15mm), single faceted stone in gallbladder, bilirubin >8mg/dL
4
Q
Early complications of acute pancreatitis
A
Shock, ARDS, renal failure, DIC or sepsis, hypocalcaemia, hyperglycaemia
5
Q
Treatment of hyperthyroidism
A
-
Antithyroid medication
- Indication: MNG, grave
- Carbimazole 10-45mg orally, daily in 2-3 divided doses
- Propylthiouracil 200-600mg orally, daily (used for women in 1st trimester of pregnancy only, has liver side effects with long-term use)
- Sustained remission of Graves’ hyperthyroidism is 12-18 months - then require more definitive management
-
Radioactive iodine
- Indication: patients unfit for surgery, elderly patients, recurrent/remitting hyperthyroidism
- Contraindicated for children (increases risk of thyroid cancer), pregnant women (suggested for women 40+ and finished family)
- Requires 2-4 months carbimazole after administration
- May eventually have hypothyroidism and require permanent thyroxine replacement
-
Surgery
- Indication: large goitres with compression symptoms, recurrent/relapsed Graves’ or toxic MNG, when malignancy cannot be excluded, cosmesis
- Pros: rapid control of symptoms without radiation exposure
- Cons: requires lifelong thyroxine replacement (low dose for Graves, high dose if malignancy - suppress TSH which minimises growth stimulation of any residual tumour, especially if metastatic)
-
Beta blockers
- Effective for controlling sweating, tremor, palpitations
- Propranolol 10mg orally BD, increasing to 40mg BD according to HR
- Diltiazem if BB contraindicated (e.g. asthmatic)
6
Q
Causes of chronic pancreatitis
A
Alcohol, familial, cystic fibrosis, haemochromatosis, congenital, pancreatic duct obstruction (stones/tumour)
7
Q
Complications of splenectomy
A
Short term: damage to surrounding structures, post operative thrombocytosis/leucocytosis, thrombosis of portal/splenic/mesenteric veins, subphrenic abscess Long term: sepsis (encapsulated organisms) - liberal use of penicillin and prophylactic vaccinations, splenosis (intraabdominal seeding of splenic tissue during removal)
8
Q
Risk factors for cholelithiasis?
A
- Cholesterol stones:
- Obesity, age <50
- Oestrogens: Female, multiparity, OCP
- Terminal ileal resection or disease (e.g. Crohn’s disease)
- Impaired gallbladder emptying: starvation, TPN, DM
- Rapid weight loss: rapid cholesterol mobilisation and biliary stasis
- Pigment stones (contain calcium bilirubinate)
- Cirrhosis
- Chronic haemolysis
- Biliary stasis (strictures, dilation, biliary infection)
- Protective factors: statins, vitamin C, coffee, exercise
9
Q
Management of chronic pancreatitis
A
- Drugs: analgesia, creon + fat soluble vitamins, insulin
- Diet: no alcohol, low fat, medium chain triglycerides
- Non-surgical: endoscopic pancreatic duct decompression, extracorporeal shockwave lithotripsy for stones, coeliac plexus block
- Surgical: pancreatectomy or pancreaticojejunostomy for those who have failed medical management, have debilitating pain, narcotic abuse, decreased weight
10
Q
Ranson criteria for predicting pancreatitis severity
A
- P: PaO2 <8kPa (60mmHg)
- A: Age >55 yo
- N: Neutrophilia (WBC >15x10^9/L)
- C: Calcium <2mmol/L
- R: Renal function - urea >16 mmol/L
- E: Enzymes - LDH >600iu/L; AST >200iu/L
- A: Albumin <32 g/L
- S: Sugar >10mmol/L
11
Q
What is thyroid storm & the management?
A
- Fever, tachycardia, vomiting, dehydration, delirium, coma, organ dysfunction (especially liver)
- Complicated by stroke
- Management:
- Admit + call specialist endocrinologist
- Block hormone synthesis and release
- Prophylthiouracil 200mg orally 4-6 hourly (blocks conversion of T4 to T3 with high dose)
- Preferred over carbimazole 20 mg orally 8 hourly
- Dexamethasone 4mg orally or IV, 12 hourly
- Propranolol (control tachy) 40-80mg orally, qid
12
Q
Consent for laparoscopic cholecystectomy
A
- What is cholecystitis: is inflammation of your gallbladder - a small pear shaped organ that sits under your liver. It is responsible for storing bile - a fluid that helps us digest fat. This bile fluid flows into the gut via a small tube called the bile duct.
- What is a cholecystectomy: surgically remove your gall bladder using a laparoscope - aka keyhole surgery (a tube like instrument with a camera and light attached). We make four very small cuts in the abdomen (one in the upper abdomen, one in the belly button and two in the right hand side of the abdomen) and insert these tube like instruments that allow us to look inside your abdomen. During this surgery we examine around your gallbladder, in particular at your bile duct for gallstones. To do this we inject a constrast medium and x-rays are taken of the bile duct.
- Anaesthetic: This procedure will require a general anaesthetic - where we put you fully asleep and put a breathing tube down your wind pipe and breathe for your during the operation.
- Having this procedure: relieve pain, nausea and vomiting, and will prevent complications and from the gallstones coming back
- Don’t have this procedure: symptoms may get better but can return and it is likely more complications will develop making treatment/surgery more difficult.
- Risks of this procedure:
- Infection - requiring antibiotics
- Bleeding - may require return to OT
- Damage to surrounding structures - blood vessels, bowel, bile duct, liver
- Small areas of lung can collapse increasing risk for infection - needing antibiotics and physiotherapy
- Heart attack or stroke due to strain on the heart
- Blood clot in the leg which can travel to the lungs
- We may need to revert to an open procedure
- We may not retrieve all stones - and these may need futher treatment in the future
- Wound infection
- Allergic reaction to contrast material
- Death as a result of this procedure is possible
- Recovery from this procedure: discharged day after operation, expect pain in abdomen for 4-5 days after operation, diet - start with fluids and move to solids, keep dressings dry and clean (replace as necessary), limited domestic duties and no driving for first 7 days, no heavy lifting for minimum 2 weeks (3-5kg MAX)
13
Q
Indications, contraindications and pre-op requirement for thyroidectomy
A
- Indications:
- Relief of local obstructive symptoms
- Diagnosis and treatment of thyroid cancer
- Control of thyrotoxicosis
- Cosmetic considerations
- Contraindications:
- Uncontrolled severe hyperthyroidism (i.e. Graves’) due to risk of intraoperative or postoperative thyroid storm
- Preoperative workup:
- Bloods: TFTs, PTH, ionised calcium
- Thyroid ultrasound for nodules
- FNAC
- CT neck useful to rule out extension
- Vocal cord function
14
Q
Pathogenesis of gallstone pancreatitis
A
- Obstruction of pancreatic duct by large or small gallstone and biliary sludge
- Backup of pancreatic enzymes
- Autodigestion of pancreas
15
Q
Indications for surgical removal of multinodular goitre
A
- Obstructive symptoms
- Thyrotoxicosis
- Suspicious or malignant changes on FNAC
- Strong family history of thyroid cancer
- Presence of retrosternal extension
- Past history of head and neck irradiation
- Cosmetic reasons (young patient with large MNG)
16
Q
Clinical features of thyrotoxicosis
A
17
Q
Management of acute pancreatitis
A
- Admit patient under surgical
- NBM + NGT if vomiting significant
- Fluid administration + fluid balance chart + early enteric nutrition
- Analgesia - morphine (2-5mg IV) or fentanyl (30-75 microg IV)
- +/- Antiemetic (10mg metoclopramide IV, 4-8mg ondansetron IV)
- Antibiotics not indicated unless infection present
- If complications arise - urgent ERCP + sphincterotomy if stone impacted in CBD or cholangitis develops
- Prevent recurrence e.g.: early cholecystectomy, alcohol counselling
If severe:
- Admit to ICU
- NBM+NGT, IV fluids, analgesia, antiemetics (as above)
- Treat hyperglycaemia, hypocalcaemia
- MRCP to confirm biliary obstruction and guide management
Infective pancreatic necrosis and pancreatic abscess
- Percutaenous aspiration of pancreatic collection - gram stain and culture
- If necessary - open surgical debridement + drain placement
- Antibiotics - piperacillin + tazobactam 4+0.5g IV, 8 hourly
18
Q
Incidence of malignancy of dominant nodule in MNG?
A
7%
More likely to be either a hyprplastic or colloid nodule
21
Q
Causes of acute pancreatitis
A
28
Q
Boundaries of anterior triangle in neck
A
- Medially: midline of neck from chin to jugular notch
- Laterally: medial border of SCM
- Superior: inferior border of mandible
