General surgery Flashcards
What features are ~ pathognomic for rectal cancer?
Tenesmus and urgency and feeling of incomplete evacuation
What are the pathological stages of developing colorectal adenocarcinoma?
Normal colon acquires defect leading to hyperproliferation of epithelium
Methylation or the APC gene causes this to develop into an adenoma/polyp
Deletion of k-ras or p53 causes this to develop into a carcinoma
Explain the dukes’ criteria?
Extent of colorectal cancer and relates to prognosis.
A = tumour within the muscular wall. Does not excees the muscularis propria
B = tumour is through the muscular wall
C = lymph node involvement (C2 = >3 nodes)
D = distant metastases
How is colorectal cancer managed?
Surgical resection with temporary defunctioning stoma
Chemotherapy post-op in stage C and above
What is the blood supply to the foregut?
Coeliac trunk
What is the blood supply to the midgut?
Superior mesenteric artery
What is the blood supply to the hundgut?
Inferior mesenteric artery
Which area of the bowel is most vulnerable to ischaemia?
Splenic flexure as is between the blood supplies of mid and hindgut
What is the main cause of bowel ischaemia?
Arterial thromboembolism
Give three risk factors for bowel ischaemia
Atrial fibrillation Increasing age Smoking Hypertension Diabetes Cocaine use
What is the difference between acute and chronic bowel ischaemia?
Acute involves sudden onset abdominal pain and requires emergency laparotomy and resection
Chronic is long-term post-prandial abdominal pain managed conservatively
What blood abnormalities are found in acute bowel ischaemia?
Leukocytosis
Raised amylase
Metabolic acidosis
What are the features of ischaemic colitis?
Arteriopathic patient
Abdominal pain (unrelated to food)
Diarrhoea
Rectal bleeding
How is ischaemic colitis managed?
Resuscitation
Early nutritional support
What are the three main complications of an acute hepatitis B infection?
Hepatocellular carcinoma
Cirrhosis
Chronic hepatitis
What are the main phases of infection with hepatitis B?
Initial phase is replicative with little liver damage and relatively normal LFTS
Second phase is inflammatory as CD8 cytotoxic cells are involved, with raised liver enzymes. Some people progress to chronic hepatitis at this point.
Some people enter the inactive phase where viral replication stops and liver enzymes normalise with no ongoing inflammation
Give 5 risk factors for developing hepatitis B
Promiscuous sexual activity Men who have sex with men Sharing drug paraphernalia Received blood transfusions or transplantation Healthcare occupation Tattoos, body piercing and acupuncture Sharing toiletry items Infants born to infected mothers Travel to high risk areas Sex workers Chronic renal failure Chronic liver disease Prison inmates and staff Hajj pilgrims
GIve three factors that increase your risk of developing chronic Hep B from an acute infection
Newborn child
Less severe acute disease
Immunocompromise
How is hepatitis B managed?
Symptoms relief Notify health protection unit Peg interferon alpha Screen for HCC test for Hep C and HIV
What is the post-exposure prophylaxis for Hep B?
Hep B immunisation at 0,1, and 6 months + immunoglobulin
Roughly how many people infected with Hep C develop a chronic infection?
Around 80%
Give 3 extra-hepatic manifestations of hepatitis
Thyroiditis Porphyria Thrombocytopenia Lichen planus Diabetes mellitus B cell lymphoproliferative disease
How is Hep C diagnosed?
Positive anti-HCV on two separate occasions, 6 months apart
Raised HCV RNA indicates active infection
How is hepatitis C managed pharmacologically?
Peg interferon alpha weekly
Daily ribavirin
Protease inhibitor
Give three side effects of Hep C treatment
Haemolytic anaemia THyroid disease Flu like illness Depression Eczema Sleep disturbance Weight loss Fatigue Alopecia Teratogenesis
What is the typical course of hepatitis A infection?
Person working/living in an institution. Vague flu like illness followed by jaundice and hepatosplenomegaly that is self-limiting
How is Hep A diagnosed?
Raised anti-HAV levels
Raised IgM indicates recent infection
Which form of viral hepatitis does not have an available vaccine?
E
What is the difference between a hepatitis coinfection and superinfection?
Co-infections mean infection occured at the same time
Superinfections mean one strain was already present and then a subsequent infection occurred
How is hepatitis D diagnosed?
Raised anti-HDV and HDV-RNA
How is Hep D managed?
Interferon alpha
How is hepatitis A managed?
Symptomatically. Rarely causes significant problems
How is Hep A transmitted?
Faeco-orally
How is Hep E transmitted?
Faeco-orally and vertically
What is the typical pattern of Hep E infection?
Incubation period of around 40 days. Often asymptomatic but if symptoms:
Pre-icteric few days of epigastric pain
Icteric phase of jaundice and arthralgia
How is Hep E diagnosed?
Raised anti-HEV IgG and anti-HEV IgM
How is Epstein Barr diagnosed?
FBC and WCC shows more than half of leukocytes are made up of lymphocytes and more than 20% of lymphocytes are atypical
Which vessels carry blood to the liver?
Portal veins
Hepatic artery
What is Budd-chiari syndrome?
Obstruction of hepatic venous outflow at any level
What can cause budd-chiari syndrome?
Hypercoagulable states
Local tumour exerting pressure
How may budd-chiari syndrome present?
Ascites with high SAAG
Hepatomegaly
RUQ pain
How is Budd-Chiari syndrome managed?
Anticoagulation
Treat ascites with spironolactone
?thrombolysis
?Transplantation
Give three causes of portal vein thrombosis
Cancer Portal hypertension Cirrhosis Intra-abdominal inflammation Thrombophilia Dehydration
Give three causes of cardiac cirrhosis
Ischaemic heart disease Valvular heart disease eg TR Cardiomyopathy Restrictive lung disease Pericardial disease
What is the triad of cardiac cirrhosis?
Hepatomegaly
Right heart failure
Ascites (raised SAAG)
What are the LFT findings in cardiac cirrhosis?
Mildly elevated AST/ALT/ALP
Raised bilirubin
Normal albumin and PT
What are three common non-specific signs of autoimmune hepatitis?
Amenorrhoea Fatigue Rheumatological disorder eg arthritis Thyroid disease Spider naevi Palmar erythema
Give 2 conditions associated with autoimmune hepatitis
Systemic sclerosis
Polymyositis
Neuritis multiplex
Polyglandular autoimmune syndrome type 3
What autoantibodies are associated with autoimmune hepatitis?
Anti nuclear factor
Smooth muscle antibodies
Anti-LKM
How is autoimmune hepatitis diagnosed?
LFTs, autoantibodies and liver biopsy
How is autoimmune hepatitis managed?
High dose corticosteroids
Immunosuppression
Give three iatrogenic causes of non-alcoholic fatty liver disease
Amiodarone Tamoxifen IV glucose therapy Parenteral nutrition Abdominal surgery Glucocorticoids
What are the findings on examination of someone with non-alcoholic fatty liver disease?
Findings of associated metabolic syndrome
RUQ pain
Hepatomegaly
What LFT abnormalities are there in non-alcoholic fatty liver disease?
Mildly raised transaminases
ALT>AST
Give three factors which increase the risk of non-alcoholic fatty liver disease progressing to cirrhosis
Increasing age Diabetes mellitus Obesity Rapid weight loss AST:ALT>1 ALT >twice normal Raised triglycerides
How should non-alcoholic fatty liver disease be managed?
Moderate and slow weight loss
Increased exercise
Treat associated metabolic syndrome features
What is a diverticula?
Herniation of colonic muscosa through the colonic muscular wall
What are the features of diverticular disease?
Change in bowel habit Rectal bleeding Abdominal pain Nausea Flatulence
Name three complications of diverticular disease
Perforation Haemorrhage Fistulae Stricturing Abscess formation
What are the features of diverticulitis?
Change in bowel habit Rectal bleeding Abdominal pain Fever High white cells Tenderness Peritonism
What are the signs of an abscess formation?
Swinging fever
High white cells
Localising signs
What is the proposed cause of diverticular disease?
Low dietary fibre
